The views and opinions expressed here are those of the authors and do not necessarily reflect the position of either Johns Hopkins University and Medicine or the University of Washington.
Older adults in congregate settings (long-term care “nursing homes”, assisted living, and group homes) have been the hardest hit by Covid-19. Devastating outbreaks have occurred, responsible for 37% of Covid-19 deaths in the United States. Many older adults have suffered intensely from the loss of contact with family members and restriction on activities, including medical appointments and outings. The most intense wave of Covid-19 cases in long-term care occurred from November 2020 to January 2021 in the United States, with more than half of states reporting all-time highest totals of long-term care cases of Covid-19 in December 2020. This spike in cases was surprising, since congregate settings for older adults have done tremendous work to prevent Covid-19. The winter wave of outbreaks and deaths in nursing homes occurred despite comprehensive infection prevention programs that included universal masking in nursing home facilities, much better (although imperfect) provision of personal protective equipment (PPE), no on-site visitors – including family members of residents – and mandated use of on-site Covid-19 rapid testing surveillance. These preventive measures were not 100% effective at keeping Covid-19 infections out of skilled nursing facilities. In fact, CDC assessed that long-term care settings continued to be affected as much as their surrounding communities.
The massive case surge in nursing homes, and resulting illness and death, led directly to the prioritization of long-term care facilities for Covid-19 vaccines. The rollout of on-site immunization in congregate settings, which started in late December, has been a great success, with on-site immunization reaching 6.6 million nursing home residents and staff as of March 24, 2021. This tremendous effort, which reached 90% of nursing homes in the first 4 weeks of the program, has been a successful collaboration with community and commercial pharmacies. Further, it builds on what we already know about seasonal influenza immunization, where vaccination is efficiently delivered directly to the most vulnerable. By going room to room, vaccine coverage in a facility can be universal in just one day.
Rollout of vaccination of long-term care staff has been slower, with some reluctance of staff to be “the first” to get immunized. This translated into only 37.5% of staff accepting immunization in the first 4 weeks of the program. These attitudes of vaccine hesitancy are understandable for staff who have been traumatized as front-line workers this year. The rapid rollout also made staff feel rushed and pressured to receive vaccine, and roll-out was not accompanied by targeted staff engagement efforts to educate about the vaccine.
After three months, with much more information available, and with 90 million Americans now immunized as of March 28, long-term care staff are becoming more willing to consider immunization, after taking time to feel more comfortable with this new technology. Education and outreach efforts focused on this workforce are now underway, with vaccine education and engagement strategies focused specifically for these workers, recognizing their unique needs. The suboptimal vaccine roll-out among long-term care staff highlighted the needs of this essential workforce, many of whom work outside of licensed patient care roles, may have limited health and science literacy, and may come from marginalized communities. The rollout also did not take into account structural barriers to signup, including need for email accounts, fears about insurance coverage for vaccination, and language barriers. The issues that long-term care staff encountered within a highly pressured roll-out environment have basically mirrored some of the structural barriers revealed in broader vaccine rollout. The challenges of reaching full vaccination coverage in long-term care serve to remind us that targeted, community-based, specific outreach is needed for successful community vaccination campaigns.
Today, we already see dramatic improvements in deaths and illness in the long-term care sector. Age-specific data from Israel show that adults older than 70 years appeared to have equivalent vaccine protection to younger populations after receiving an mRNA vaccine; some preliminary data from nursing facilities in Connecticut released by CDC also show protection, even accounting for the aging immune systems of long-term care residents. This is exciting data, especially because the older and frailer nursing home population has been shown to have reduced vaccine efficacy from other vaccines.
Monoclonal antibodies may be able to bridge the gap to protect long-term care residents and staff and save lives when vaccine coverage is not 100% or in cases of vaccine breakthrough infection. Preliminary data have been released from the Blaze-2 study, which showed that bamlanivimab decreased acquisition of Covid-19 among exposed long-term care residents and staff, and also decreased symptomatic Covid-19 disease among those infected. Monoclonal antibodies are available in the U.S. under Emergency Use Authorization, and data continue to accumulate on their safety and efficacy in long-term care populations.
Some future areas of focus for Covid-19 immunization in congregate settings include the need for consistent, careful, and respectful outreach to staff to help them have the information they need to consider vaccination. Since immunization is more accepted and the safety profile of vaccinations now established at the population level, many staff are reconsidering their initial choice to wait before getting immunized, and are now interested in vaccination. Even for facilities with high initial uptake of immunization, new staff are constantly onboarding, so access to vaccine education and to vaccination will need to be a continuous process. Similarly, new patient admissions to skilled nursing facilities, rehabilitation centers, and assisted living settings continue, and there is a need to immunize older adults new to facilities, or those who did not choose to be immunized but now would like to do so.
Now Medicare/ Centers for Medicare & Medicaid Services (CMS) has released a new policy framework directing long-term care facilities to invite loved ones back into facilities for indoor visitation. The directions include when to suspend visitation (such as if new cases of Covid-19 occur in a facility) and remind us that long-term care facilities also will continue to conduct routine on-site Covid-19 surveillance testing for all residents and staff. Visitors are not required to be vaccinated to visit their loved ones but all visitors must adhere to facility infection control practices, which require universal masking at this time. While social distancing continues to be encouraged, CMS specifically encourages touching and hugs of vaccinated residents who are wearing a well-fitted face mask.
Skilled nursing homes, long-term care facilities, and assisted living residences were the site of tremendous suffering during the past year. It is incredibly promising that vaccination appears to be bringing a brighter future for residents, family, and staff.
Alison Roxby, MD, MSc, is an infectious disease physician-scientist and Associate Professor of Medicine, Global Health, and Epidemiology at the University of Washington. Since the start of the Covid-19 pandemic, she has been involved in outbreak investigation and surveillance in skilled nursing facilities and assisted living settings, and brings that expertise to the Coronavirus Prevention Network. With a goal to fully incorporate older adults into Covid-19 prevention research, she has focused her efforts on community engagement with older adults and those who work with them, and expert protocol review to allow the fullest inclusion of older adults into vaccine and monoclonal antibody trials.